the nurse is assisting with the admission of a young adult female korean exchange student with acute abdominal pain although the client has been able
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam 2024

1. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

2. What is the first step in using an automated external defibrillator (AED) on a patient who has collapsed?

Correct answer: B

Rationale: The correct answer is B: Turn on the AED and follow the voice prompts. This is the first step in using an AED as the device will guide you through the process of analyzing the heart rhythm and delivering a shock if necessary. Choice A, applying the pads to the chest, comes after turning on the AED. Checking the patient's pulse (Choice C) is not necessary before using an AED as the device is specifically designed to assess the need for defibrillation. Ensuring the area is clear (Choice D) is important for safety but is not the initial step in using an AED.

3. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?

Correct answer: C

Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.

4. A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.

5. What information should the PN collect during the admission assessment of a terminally ill client to an acute care facility?

Correct answer: B

Rationale: Correct Answer: B. Understanding the client's wishes regarding organ donation is crucial as it aligns with end-of-life care preferences and ensures that the client's decisions are respected. While obtaining the name of a funeral home (Choice A) may be necessary, it is not typically part of the initial admission assessment. Contact information for the client's next of kin (Choice C) is important for communication but may not be directly related to the client's immediate end-of-life wishes. Health care proxy information (Choice D) is vital for decision-making if the client becomes incapacitated but may not be the primary focus during the initial admission assessment.

Similar Questions

The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?
Which cranial nerve is responsible for the sense of smell?
When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?
Which hormone is primarily responsible for the regulation of calcium and phosphate in the blood?
A registered nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line, and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses